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Wednesday, June 11, 2014

Stop Trying to Punish the Error Out of People!

We’ve talked about things this like before (here, here, here, and here) but we
once again see examples of a really bad habit organizations, governments, and,
in general, people have – punishing people for human error. The most recent
example is the crash involving comedian Tracy Morgan, who, as of the time of
this writing is still in critical condition, where four people were injured and
one was killed. Prosecutors have charged the truck driver with vehicular
manslaughter and assault by auto, citing the fact that he was awake for more
than 24 hours before the crash.

Let’s forget the fact that the driver is being punished for
an outcome he couldn’t control (after all, if he was awake for 24 hours but DID
NOT get into an accident simply because of luck, would he have been charged
with anything?). Let’s just look at the idea of punishing the human error.

First, we have to assume one thing – the driver did not
intend to crash into the limo that was carrying Morgan and company. If the
driver did intend to cause harm then punishment may be deserved, but it’s
pretty unlikely this is the case.

What happened then? The truck driver was tired and likely
made a mistake. The remedy? In a scene akin to the witch burning scene in Monty Python and the Quest for the Holy Grail, we are looking for someone to
punish and the driver is an easy target.

After all, assuming it’s true, how could he be so stupid as
to stay up that long before driving?

Indeed, that is the question. We have to remember that if
anyone has “put their money where their mouth is,” or, to use a more
appropriate colloquialism, “has skin in the game” it’s the driver. In this case
staying up too much led to injury and death to others, but in many cases it can
lead to injury or death for the driver. So right off the bat the driver has a
vested interest in being safe. So the problem isn’t one of motivation.

Further, we should also admit that if you asked any truck
driver if they went without sleep for a long period of time whether they would
be a less safe driver that this would not be news to them. Most know that being
fatigued makes you an unsafe driver. So the problem isn’t knowledge.

So, if truck drivers want to be safe drivers and if they
know that they should get enough rest before driving, why did this accident
happen?

The convenient answer is to say that this particular truck
driver was particularly bad and therefore deserves punishment.

…but what if the problem isn’t just with this driver? What
if this truck driver isn’t really that much different than any other truck
driver? What if the issue is unreasonable production schedules, faulty
procedures and regulations, and incentive structures that reward drivers for
driving while tired? What good is punishing them going to do?

Obviously the answer is – nothing. However, you could argue
that punishing human error in situations where it is a system problem actually
makes things worse. What ends up happening is that workers go into defensive
mode. Rather than incidents being opportunities to learn, they become times to
find fault for some and duck for cover for others. The bottom line, as Todd Conklin says, you can either choose to find fault and blame, or you can learn.
You can’t do both. If we choose fault and blame, like we always do, then we
will get what we always got. And that means more accidents, more injuries, and
more deaths.